Consent for the Disposal of Septage

CONSENT FOR THE DISPOSAL OF SEPTAGE
INSTRUCTIONS: This form is for the purpose of providing the Oklahoma Department of Environmental Quality (DEQ) with
proof of a permitted disposal facility’s consent for the disposal of septage. Complete one form for each facility.
DISPOSAL LOCATION (Check One)
WASTE WATER TREATMENT FACILITY*
SOLID WASTE LANDFILL
SEPTAGE TREATMENT FACILITY* CITY PERMITTED PRETREATMENT FACILITY*
Name: Facility/Permit No.:
Mailing Address: City State Zip
Street Address/Location City State Zip
I, ___________________, representing the above-named facility, understand that by signing this
Printed Name
Consent Form, I am certifying to the DEQ that this facility consents to the disposal of septage by
(Business Name of Licensed Septage Pumper and Hauler)
effective and ending January 31, 20 .
(Start Date) (End Date)
Signature Title Date
DEQ Form No. 645-004 Rev. 07/01/2010

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CONSENT FOR THE DISPOSAL OF SEPTAGE
INSTRUCTIONS: This form is for the purpose of providing the Oklahoma Department of Environmental Quality (DEQ) with
proof of a permitted disposal facility’s consent for the disposal of septage. Complete one form for each facility.
DISPOSAL LOCATION (Check One)
WASTE WATER TREATMENT FACILITY*
SOLID WASTE LANDFILL
SEPTAGE TREATMENT FACILITY* CITY PERMITTED PRETREATMENT FACILITY*
Name: Facility/Permit No.:
Mailing Address: City State Zip
Street Address/Location City State Zip
I, ___________________, representing the above-named facility, understand that by signing this
Printed Name
Consent Form, I am certifying to the DEQ that this facility consents to the disposal of septage by
(Business Name of Licensed Septage Pumper and Hauler)
effective and ending January 31, 20 .
(Start Date) (End Date)
Signature Title Date
DEQ Form No. 645-004 Rev. 07/01/2010